Provider Demographics
NPI:1396822870
Name:PINE STREET DERMATOLOGY, PC
Entity Type:Organization
Organization Name:PINE STREET DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:COVELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-574-9101
Mailing Address - Street 1:1233 LOCUST ST.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-735-2636
Mailing Address - Fax:215-735-2634
Practice Address - Street 1:1233 LOCUST ST.
Practice Address - Street 2:SUITE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-735-2636
Practice Address - Fax:215-735-2634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067435L174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2146941000OtherIBC
PA1458723OtherHIGHMARK BLUE SHIELD
PA3150557OtherAETNA
PA2146941000OtherIBC
PADB2996Medicare PIN